Chronic Pain and Opioids

What are opioids and what can they do for me?

  • Opioids are a group of medications that act in the brain, spinal cord and peripheral nerves to reduce the sensation of pain.
  • Opioids are definitely appropriate to relieve acute and end-of-life pain (where "being more active" may or may not be an issue). For chronic non-cancer pain, the goal is to improve function through reducing pain. Pain may never completely disappear if medication is the only treatment, and continued use is meant to be contingent on achieving that goal.
  • Opioids should only be considered for chronic pain after non-drug therapies (e.g. cognitive behavioural therapy, physical therapy, exercise) and non-opioid medications have been given an adequate trial or are deemed inappropriate. 
  • If opioids are used for pain control it is important to periodically revisit treatment and reassess if they are still needed.  A physician may try reducing a patient’s dose to see if the same effect can be achieved with lower doses or with non-opioid or non-medication treatment.

What are the side effects of opioids and how are they managed?

Common side effects include:

  • constipation – patients should discuss a regular bowel regimen (e.g. laxatives, fibre supplements, high-fibre foods) with their physician, as it is easier to prevent constipation than it is to treat it
  • nausea/vomiting – patients should discuss anti-nausea drugs with their physician, usually only needed short-term until the patient’s body adjusts to the medication
  • drowsiness – as the patient’s body adjusts to the medication, drowsiness should subside but must be considered when caring for others, operating machinery or driving
  • dry skin/itching – this does not always indicate the patient is allergic to the medication
  • sweating
  • dry mouth
  • confusion
  • tolerance – this may require the patient to take more medication for the same pain relief
  • physical dependence – leads to physical withdrawal when the medication is stopped abruptly
  • increased sensitivity to pain
  • hormone problems leading to decreased testosterone (affecting libido, strength, performance and erectile dysfunction) and changes to menstrual cycle/flow
  • mental health issues including depression and anxiety 
  • car accidents

A physician can increase the dose very slowly to reduce the risk of side effects and to allow the patient’s body enough time to adjust to the medication. 

A patient may need to switch to another opioid, stop opioids altogether, or use additional medications to manage the side effects.

What are the risks of taking opioids?

  • Combining opioids with other medications such as sleep aids (prescription or non-prescription) or substances (such as alcohol) increase the risk for serious side effects or drug interactions including overdose. Patients are encouraged to talk to their physician and pharmacist. 
  • Patients with sleep apnea, other sleeping disorders or respiratory disease should take special precautions.
  • Discuss safety issues such as driving and caring for others (children or elderly). Do not drive when starting a medication regimen or when increasing the dose, as the patient may become sleepy or confused.
  • Opioid medication has the ability to cause psychological dependence (addiction) as well as physical dependence. A physician will undertake a thorough evaluation of a patient’s risk factors for developing addiction, as research shows that as many as one in four patients receiving prescription opioids long term in a primary care setting struggles with addiction. Signs of psychological dependence include drug craving, and an urge to use the opioid to “get high” or for mood change.
  • Addiction is a disease that includes loss of control over the use of a medication, compulsion about obtaining it, and continued use despite negative consequences. Common examples of addictive behaviours include using up prescription medication early and obtaining it from other sources. If patients feel they are losing control, it is cricial that they be assessed for possible addiction by raising the issue with their physician.
  • Safe storage is important so that others are protected from taking a patient’s medication. A lockbox or safe are ideal. Medications should not be stored in the kitchen or bathroom because there is a risk of inadvertent use by other family members/friends.
  • Naloxone is used to treat opioid overdose. Patients should discuss with their physician whether it should be on hand in order to treat overdose and decrease risk of harm. Naloxone is now available in BC without a prescription. Patients and their family members should be aware of the signs of overdose and how to use naloxone to treat it.

What if I stop taking my medication abruptly?

  • Withdrawal may occur. Withdrawal does not mean that a patient is addicted. It means that the patient’s body has become used to having the drug in their system and it has been stopped too quickly. 
  • Withdrawal is not dangerous, but it can be uncomfortable if done too quickly. Symptoms are similar to the flu—pain, nausea, chills, body aches and diarrhea.
  • If a medication is to be stopped, a slow, gradual decrease (tapering) is best. The patient’s physician and pharmacist can work together to develop a schedule for tapering medication.

How can I partner with my physician to optimize my treatment and keep me safe?

  • Patients can keep an activity and pain diary to help them work towards functional goals, track triggers and develop a plan to manage them. Rate pain on a scale of 1 to 10 and identify any potential causes when increases occur. 
  • Patients and physicians should set goals together and focus on functional improvements – for example, plan to return to previous activities that give the patient happiness and engage him or her in the community.
  • Patients can incorporate non-medication treatment options including such modalities as massage, physiotherapy and acupuncture.
  • Patients should see their physician regularly. The physician can assess pain relief, side effects, and revisit goals. Talk to them about any side-effects you experience, and any concerns you have.
  • Patients can consider non-opioid treatment options such as Tylenol, ibuprofen, muscle rubs, heating pads and cold packs, for less active days.
  • Patients should take opioids only as instructed by their physician, and never in greater amounts or more often than prescribed.
  • Patients must not share medications with others. They may have allergic or adverse reactions.
  • Patients should avoid other drugs while taking opioids. Benzodiazepines such as lorazepam (Ativan) or alprazolam (Xanax), sleep aids like zopiclone or Sublinox, muscle relaxants and other prescription opioid pain relievers should be avoided unless specifically advised by a physician.
  • Patients should avoid alcohol, tobacco and street drugs.
  • Patients should discuss and sign a treatment agreement with their physician, which may include:
    • urine drug testing – a urine sample will help show all the drugs the patient is taking and ensure that a combination is not placing the patient at risk; the test includes checking for fentanyl, which is being used illicitly to contaminate a variety of drugs and places people who use them at risk
    • pill/patch counts and comparison to dispensing dates to track compliance
    • policy on early refills – the physician will prescribe enough medication to last until the patient’s next visit; if the patient runs out too soon or loses their prescription, their physician will not likely provide another one; safe use and storage are the patient’s responsibility
    • single providers – it is advisable to see only one physician and one pharmacy for continuity of care and to establish a collaborative, trusting relationship
  • Patients should store medications safely and return them to the pharmacy for safe disposal if no longer taking them.